Canadian Tertiary Care Hospital Research Articles

Cerebrospinal Fluid Shunt Infections: A Multicenter Pediatric Study.

Infections complicate 5%-10% of cerebrospinal fluid (CSF) shunts. We aimed to describe the characteristics and contemporary pathogens of shunt infections in children in Canada and the United States. Descriptive case series at tertiary care hospitals in Canada (N = 8) and the United States (N = 3) of children up to 18 years of age with CSF shunt infections from July 1, 2013, through June 30, 2019. There were 154 children (43% female, median age 2.7 years, 50% premature) with ≥1 CSF shunt infections. Median time between shunt placement and infection was 54 days (interquartile range, 24 days-2.3 years). Common pathogens were coagulase-negative staphylococci (N = 42; 28%), methicillin-susceptible Staphylococcus aureus (N = 24; 16%), methicillin-resistant S. aureus (N = 9; 5.9%), Pseudomonas aeruginosa (N = 9; 5.9%) and other Gram-negative bacilli (N = 14; 9.0%). Significant differences between pathogens were observed, including timing of infection (P = 0.023) and CSF leukocyte count (P = 0.0019); however, differences were not sufficient to reliably predict the causative organism based on the timing of infection or discriminate P. aeruginosa from other pathogens based on clinical features. Empiric antibiotic regimens, which included vancomycin (71%), cefotaxime or ceftriaxone (29%) and antipseudomonal beta-lactams (33%), were discordant with the pathogen isolated in five cases. There was variability between sites in the distribution of pathogens and choice of empiric antibiotics. Nine children died; 4 (44%) deaths were attributed to shunt infection. Staphylococci remain the most common cause of CSF shunt infections, although antibiotic resistant Gram-negative bacilli occur and cannot be reliably predicted based on clinical characteristics.

Unexplained Significant Central Sleep Apnea in Infants: Clinical Presentation and Outcomes.

Unexplained significant central sleep apnea in term infants presents as central apneas with associated oxygen desaturations requiring respiratory support and monitoring for prolonged periods. However, there is a paucity of literature describing idiopathic central sleep apnea (ICSA) in term or near-term infants. Our aim was to describe the clinical manifestations, polysomnography data, interventions, and trajectory of ICSA in infants. This is a retrospective study of infants (gestational age ≥ 35weeks) who presented with significant central apneas and were subsequently diagnosed with ICSA following polysomnography and clinical investigations between January 2011 and April 2021 at a tertiary care hospital in Canada. Polysomnography data, clinical investigations, and treatments were documented. Eighteen infants (male, 78%; median gestational age 38weeks) with ICSA were included. Initial polysomnograms were completed at a median (interquartile range [IQR]) age of 1.2 (0.6-1.6) months (n = 18) and follow-up polysomnograms at 12.4 (10.6-14.0) months (n = 13). Compared to baseline diagnostic polysomnograms, at follow-up there was a significant reduction in the median (IQR) central apnea-hypopnea index (26.1 [18.2-52.9] versus 4.2[2.6-7.2] events/hour; p = 0.001), desaturation index (30.9 [12.2-57.4] versus 3.9[3.0-7.9] events/hour; p = 0.002), average transcutaneous carbon dioxide (41.9 [40.1-47.3 versus 39.4[37.5-42.7] mmHg; p = 0.025), and improved nadir oxygen saturation (79.8 [69.1-83.0] versus 85.5[83.2-87.8]%; p = 0.033), respectively. Prescribed treatments included supplemental oxygen (14/18, 78%), caffeine (5/18, 28%), and noninvasive ventilation (1/18, 6%). Infants with significant unexplained ICSA have a favorable clinical trajectory over time. Further research is needed to understand the etiology of this rare disorder.

Diagnosis of Endometriosis at Laparoscopy: A Validation Study Comparing Surgeon Visualization with Histologic Findings.

This study aimed to evaluate the validity of laparoscopic visualization for the diagnosis of endometriosis compared with histopathology. We conducted a retrospective chart review at a tertiary care hospital in Canada for the period of April 1, 2016 to March 31, 2017. Of 1069 women, 96 were selected for having undergone laparoscopic visualization and concurrent histopathological biopsy for suspected endometriosis. Standard measures of validity for diagnostic tests (sensitivity, specificity, positive predictive and negative predictive values, accuracy) were used. Mean age of the 96 women included was 40 ± 7.2 years, and median gravidity and parity were 1 (IQR 0-3) and 0 (IQR 0-2), respectively. Common symptoms were abdominal and pelvic pain (41.7%), menstrual bleeding concerns (34.4%), dysmenorrhea (29.2%), and infertility (8.3%). Approximately one-third of women had endometriomas (31.3%), while more than half had deep infiltrating endometriosis (59.4%). The diagnosis of endometriosis was made by surgeons at laparoscopic visualization in 82.3% of women and by histopathology in 74.0%. Using histopathology as the gold standard, sensitivity for laparoscopic visualization was 90.1% (95% CI 81.0-95.1), while specificity was 40.0% (95% CI 23.4-59.3). Positive and negative predictive values were 81.0% (95% CI 71.0-88.1) and 58.8% (95% CI 36.0-78.4), respectively; and the accuracy was 77.1% (95% CI 67.7-84.4). Although laparoscopic visualization had relatively high sensitivity and positive predictive value, its specificity and negative predictive value were relatively low. These findings support the use of laparoscopic visualization with histopathological analysis for accurate diagnosis of endometriosis.

Economic feasibility of a novel tool to assist extubation decision-making: an early health economic modeling.

To estimate the minimum percent change in failed extubation to make a tool designed to reduce extubation failure (Extubation Advisor [EA]) economically viable. We conducted an early return on investment (ROI) analysis using data from intubated intensive care unit (ICU) patients at a large Canadian tertiary care hospital. We obtained input parameters from the hospital database and published literature. We ran generalized linear models to estimate the attributable length of stay, total hospital cost, and time to subsequent extubation attempt following failure. We developed a Markov model to estimate the expected ROI and performed probabilistic sensitivity analyses to assess the robustness of findings. Costs were presented in 2020 Canadian dollars (C$). The model estimated a 1 percent reduction in failed extubation could save the hospital C$289 per intubated patient (95 percent CI: 197, 459). A large center seeing 2,500 intubated ICU patients per year could save C$723,124/year/percent reduction in failed extubation. At the current annual price of C$164,221, the EA tool must reduce extubation failure by at least 0.24 percent (95 percent CI: .14, .41) to make the tool cost-effective at our site. Clinical decision-support tools like the EA may play an important role in reducing healthcare costs by reducing the rate of extubation failure, a costly event in the ICU.

ICD-10 Diagnostic Coding for Identifying Hospitalizations Related to a Diabetic Foot Ulcer.

To estimate the positive predictive value (PPV) of Canadian ICD-10 diagnostic coding for the identification of hospitalization related to a diabetic foot ulcer (DFU). Hospitalizations related to a neuropathic and/or ischemic DFU were identified from the Discharge Abstract Database (DAD) records of a single Canadian tertiary care hospital between April 1, 2002 and March 31, 2019. The first coding approach required a most responsible diagnosis (MRDx) code for diabetes-specific foot ulceration or gangrene (DSFUG group). Three alternative coding approaches were also considered: MRDx code for lower-limb osteomyelitis (osteomyelitis group); lower-limb ulceration (LLU group); or lower-limb atherosclerotic gangrene (atherosclerosis group)-each in conjunction with a non-MRDx DSFUG code on the same DAD record. From all eligible DAD records, random samples were drawn for each coding group. DAD records were independently compared by a masked reviewer who manually abstracted data from the entire hospital record (reference standard). The PPV and 95% CI were generated. Out of 1,460 hospitalizations, a total of 300, 50, 33 and seven records were included from the DSFUG, osteomyelitis, LLU and atherosclerosis samples, respectively. Compared to the reference standard, the PPV for all 390 records was 88.5% (95% CI 84.9 to 91.5). The DSFUG group had the highest PPV (90.0%, 95% CI 86.0 to 93.2), followed by the atherosclerosis (85.7%, 95% CI 42.1 to 99.6), LLU (84.9%, 95% CI 68.1 to 94.9) and osteomyelitis (82.0%, 95% CI 68.6 to 91.4) groups. Based on data from a Canadian tertiary care hospital, the specified coding algorithms can be used to identify and study the management and outcomes of people hospitalized with a DFU in Ontario.

Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada

The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown. To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic. This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included. COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020). Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data. Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; β coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (β coefficient, 5.97; P < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (β coefficient, -0.008 vs 3.23; P < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P < .001). This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

748. The Changing Epidemiology of Clostridioides difficile Infection and the NAP1/027 Strain in Two Quebec Hospitals

BackgroundIn 2003, many hospitals in Québec, Canada experienced an increase in the incidence of healthcare-associated C. difficile infection (HA-CDI) associated with increased morbidity and mortality. This increase was associated with the dissemination of the NAP1/027 strain. The objective of this study was to describe the epidemiology of HA-CDI in two tertiary care hospitals based in Montréal from 2003 to 2019.MethodsSurveillance for HA-CDI was performed using standard definitions from 2003 to 2019 at the Montreal General Hospital (MGH) and Royal Victoria Hospital (RVH), in Montréal, Québec. C. difficile was isolated from stool specimens using standard methods. Pulsed field gel electrophoresis and ribotyping were performed to determine genotype. Antibiotic utilization and infection control interventions implemented over the same time period were reviewed. ResultsA total of 4314 cases of CDAD were identified during the study period: 2295 at the RVH and 2019 at the MGH. The incidence decreased from 29.5 to 5.9 cases per 10,000 patient-days between 2003 and 2019 at the RVH and from 23.8 to 3.9 cases per 10,000 patient-days at the MGH. Of the 124 isolates available for genotyping in 2003, 112 were NAP1 (90.3%) compared to 5 out of 53 (9.4%) in 2019. Fluoroquinolone utilization decreased from 230 to 139 DDDs per 1,000 patient-days between 2003 and 2019, whereas total antibiotic utilization increased from 1296 to 1550 DDDs per 1,000 patient-days. Infection Control interventions included empirically placing patients with diarrhea on precautions, intensified cleaning measures, formal antibiotic stewardship, introduction of a real-time PCR C. difficile test in June 2010, and a move to a facility with only single rooms at the RVH in April 2015. Incidence of HA-CDI at the RVH and MGH and antibiotic utilization between 2003 and 2019 ConclusionAn important change in HA-CDI epidemiology was observed in two Canadian tertiary care hospitals based in Montréal between 2003 and 2019. There was a significant decrease in incidence of HA-CDI and a genotype shift from a predominance of NAP1 strains to non-NAP1 strains. Utilization of fluoroquinolones, to which the NAP1 strain is resistant, concurrently decreased. Infection control interventions targeting isolation, diagnosis, disinfection, and antibiotic stewardship have contributed to the major observed reduction in HA-CDI incidence.Disclosures All Authors: No reported disclosures

Clinicians’ Perspectives After Implementation of the Serious Illness Care Program

Discussions about goals of care with patients who are seriously ill typically occur infrequently and late in the illness trajectory, are of low quality, and focus narrowly on the patient's resuscitation preferences (ie, code status), risking provision of care that is inconsistent with patients' values. The Serious Illness Care Program (SICP) is a multifaceted communication intervention that builds capacity for clinicians to have earlier, more frequent, and more person-centered conversations. To explore clinicians' experiences with the SICP 1 year after implementation. This qualitative study was conducted at 2 tertiary care hospitals in Canada. The SICP was implemented at Hamilton General Hospital (Hamilton, Ontario) from March 1, 2017, to January 19, 2018, and at Foothills Medical Centre (Calgary, Alberta) from March 1, 2018, to December 31, 2020. A total of 45 clinicians were invited to participate in the study, and 23 clinicians (51.1%) were enrolled and interviewed. Semistructured interviews of clinicians were conducted between August 2018 and May 2019. Content analysis was used to evaluate information obtained from these interviews between May 2019 and May 2020. The SICP includes clinician training, communication tools, and processes for system change. Clinicians' experiences with and perceptions of the SICP. Among 23 clinicians interviewed, 15 (65.2%) were women. The mean (SD) number of years in practice was 14.6 (9.1) at the Hamilton site and 12.0 (6.9) at the Calgary site. Participants included 19 general internists, 3 nurse practitioners, and 1 social worker. The 3 main themes were the ways in which the SICP (1) supported changes in clinician behavior, (2) shifted the focus of goals-of-care conversations beyond discussion of code status, and (3) influenced clinicians personally and professionally. Changes in clinician behavior were supported by having a unit champion, interprofessional engagement, access to copies of the Serious Illness Conversation Guide, and documentation in the electronic medical record. Elements of the program, especially the Serious Illness Conversation Guide, shifted the focus of goals-of-care conversations beyond discussion of code status and influenced clinicians on personal and professional levels. Concerns with the program included finding time to have conversations, building transient relationships, and limiting conversation fluidity. In this qualitative study, hospital clinicians described components of the SICP as supporting changes in their behavior and facilitating meaningful patient interactions that shifted the focus of goals-of-care conversations beyond discussion of code status. The perceived benefits of SICP implementation stimulated uptake within the medical units. These findings suggest that the SICP may prompt hospital culture changes in goals-of-care dialogue with patients and the care of hospitalized patients with serious illness.

Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals.

Background: Disease-associated malnutrition (DAM) is common in hospitalized children. This survey aimed to assess current in-hospital practices for clinical care of pediatric DAM in Canada. Methods: An electronic survey was sent to all 15 tertiary pediatric hospitals in Canada and addressed all pillars of malnutrition care: screening, assessment, treatment, monitoring and follow-up. Results: Responses of 120 health care professionals were used from all 15 hospitals; 57.5% were medical doctors (MDs), 26.7% registered dietitians (RDs) and 15.8% nurses (RNs). An overarching protocol for prevention, detection and intervention of pediatric malnutrition was present or “a work in progress”, according to 9.6% of respondents. Routine nutritional screening on admission was sometimes or always performed, according to 58.8%, although the modality differed among hospitals and profession. For children with poor nutritional status, lack of nutritional follow-up after discharge was reported by 48.5%. Conclusions: The presence of a standardized protocol for the clinical assessment and management of DAM is uncommon in pediatric tertiary care hospitals in Canada. Routine nutritional screening upon admission has not been widely adopted. Moreover, ongoing nutritional care of malnourished children after discharge seems cumbersome. These findings call for the adoption and implementation of a uniform clinical care pathway for malnutrition among pediatric hospitals.

Current practices and policies regarding the use of high-flow nasal cannula on general pediatric inpatient wards in Canada.

High-flow nasal cannula (HFNC) oxygen therapy has become a common treatment for respiratory conditions in children. To our knowledge, no study has described practice patterns for HFNC on pediatric inpatient wards in Canada. The aim of this study was to survey current practices and policies regarding the use of HFNC on the ward in children's hospitals in Canada. We conducted a web-based survey of Pediatric Hospital Medicine section chiefs in major tertiary care hospitals in Canada. The primary outcome was the proportion of hospitals that use HFNC on the general pediatric ward. Secondary outcomes included indications for HFNC, initial and maximum flow rates, maximum FiO2, method of nutrition delivery while on HFNC, level of nursing and respiratory therapist care required, criteria for pediatric intensive care unit transfer, and subjective successes and challenges of implementing a ward-based HFNC policy. The section chief survey response rate was 100% (15/15). Eight centres (53%) allowed the use of HFNC outside of an intensive care setting. Six centres initiated HFNC on the ward, while two centres only accepted patients after HFNC had been initiated in an intensive care setting. Other practices and policies varied considerably from centre to centre. Our study reveals that approximately half of tertiary children's hospitals in Canada currently use HFNC on the ward and utilize a range of practices and policies. Other centres are considering implementation. Further research is needed to inform best practices for HFNC therapy, support stewardship of health care resources, and promote safe patient care.

Does Personality Matter? Perceptions and Experiences of Introverts and Extraverts as General Surgeons

Phenomenon Medical educators increasingly recognize both the challenges introverts, compared to extraverts, may face in medical training and the unique strengths they bring to practice. However, few researchers have examined in-depth how introverts and extraverts truly experience training and practice, particularly in specialties like surgery that tend to value qualities (e.g., dominance and assertiveness) typically associated with extraverts. This study aimed to explore the perceptions and experiences of individuals with both personalities within the field of general surgery. Approach Using a constructivist grounded theory approach, six general surgeons and 10 general surgery residents who identified as introverted, extraverted, or ambiverted were recruited from two Canadian tertiary care hospitals to participate in semi-structured interviews. Data collection and analysis occurred iteratively, and data were analyzed using open, selective, and thematic coding. Constant comparison allowed us to make sense of the similar and dissimilar views that emerged from each interview. Findings Irrespective of their personalities, participants voiced two general patterns of responses. Some participants believed that “personality doesn’t matter”: that both introverted and extraverted practice styles were equally viable and neither introverts nor extraverts would find surgical training more challenging than the other (culture of equality). However, others believed that “personality matters,” emphasizing that surgeons should be dominant and aggressive leaders. Only those who believed “personality matters” felt that introverts sometimes needed to act more extraverted in order to succeed in surgical training (culture of hierarchy). Similar numbers of introverts and extraverts adhered to each viewpoint. Insights Our qualitative approach allowed us to draw meaning from the complex subjective experiences of our research participants. Our findings suggest that two competing cultures (equality and hierarchy) co-exist within the field of surgery and that trainees, depending on which culture they adhere most to, will or will not “adapt” their personalities to the workplace. These findings deepen our understanding of the nuances of surgical culture and have important implications for how we select candidates based on personality.

Myocardial strain assessment using cardiovascular magnetic resonance imaging in recipients of implantable cardioverter defibrillators

BackgroundCardiovascular magnetic resonance (CMR) is increasingly used in the evaluation of patients who are potential candidates for implantable cardioverter-defibrillator (ICD) therapy to assess left ventricular (LV) ejection fraction (LVEF), myocardial fibrosis, and etiology of cardiomyopathy. It is unclear whether CMR-derived strain measurements are predictive of appropriate shocks and death among patients who receive an ICD. We evaluated the prognostic value of LV strain parameters on feature-tracking (FT) CMR in patients who underwent subsequent ICD implant for primary or secondary prevention of sudden cardiac death.MethodsConsecutive patients from 2 Canadian tertiary care hospitals who underwent ICD implant and had a pre-implant CMR scan were included. Using FT-CMR, a single, blinded, reader measured LV global longitudinal (GLS), circumferential (GCS), and radial (GRS) strain. Cox proportional hazards regression was performed to assess the associations between strain measurements and the primary composite endpoint of all-cause death or appropriate ICD shock that was independently ascertained.ResultsOf 364 patients (mean 61 years, mean LVEF 32%), 64(17.6%) died and 118(32.4%) reached the primary endpoint over a median follow-up of 62 months. Univariate analyses showed significant associations between GLS, GCS, and GRS and appropriate ICD shocks or death (all p < 0.01). In multivariable Cox models incorporating LVEF, GLS remained an independent predictor of both the primary endpoint (HR 1.05 per 1% higher GLS, 95% CI 1.01–1.09, p = 0.010) and death alone (HR 1.06 per 1% higher GLS, 95% CI 1.02–1.11, p = 0.003). There was no significant interaction between GLS and indication for ICD implant, presence of ischemic heart disease or late gadolinium enhancement (all p > 0.30).ConclusionsGLS by FT-CMR is an independent predictor of appropriate shocks or mortality in ICD patients, beyond conventional prognosticators including LVEF. Further study is needed to elucidate the role of LV strain analysis to refine risk stratification in routine assessment of ICD treatment benefit.

Pediatric Hyperacute Arterial Ischemic Stroke Pathways at Canadian Tertiary Care Hospitals.

Childhood acute arterial ischemic stroke (AIS) is diagnosed at a median of 23 hours post-symptom onset, delaying treatment. Pediatric stroke pathways can expedite diagnosis. Our goal was to understand the similarities and differences between Canadian pediatric stroke protocols with the aim of optimizing AIS management. We contacted neurologists at all 16 Canadian pediatric hospitals regarding AIS management. Established protocols were analyzed for similarities and differences in eight domains. Response rate was 100%. Seven (44%) centers have an established AIS protocol and two (13%) have a protocol under development. Seven centers do not have a protocol; two redirect patients to adult neurology, five rely on a case-by-case approach for management. Analysis of the seven protocols revealed differences in: 1) IV-tPA dosage: age-dependent 0.75-0.9 mg/kg (N = 1) versus age-independent 0.9 mg/kg (N = 6), with maximum doses of 75 mg (N = 1) or 90 mg (N = 6); 2) IV-tPA lower age cut-off: 2 years (N = 5) versus 3 or 10 years (each N = 1); 3) IV-tPA exclusion criteria: PedNIHSS score <4 (N = 3), <5 (N = 1), <6 (N = 3); 4) first choice of pre-treatment neuroimaging: computed tomography (CT) (N = 3), magnetic resonance imaging (MRI) (N = 2) or either (N = 2); 5) intra-arterial tPA use (N = 3) and; 6) mechanical thrombectomy timeframe: <6 hour (N = 3), <24 hour (N = 2), unspecified (N = 2). Although 44% of Canadian pediatric hospitals have established AIS management pathways, several differences remain among centers. Some criteria (dosage, imaging) reflect adult AIS literature. Canadian expert consensus regarding IV-tPA and endovascular treatment should be established to standardize and implement AIS protocols across Canada.

Multidisciplinary Team versus a "Phosphate-Counting" App for Serum Phosphate Control: A Randomized Controlled Trial.

Hyperphosphatemia is almost universal in well-nourished patients with ESKD treated with dialysis due to an imbalance between dietary intake and phosphate removal via residual kidney function and dialysis. Although food phosphate content can vary dramatically between meals, the current standard is to prescribe a fixed dose of phosphate binder that may not match meal phosphate intake. The primary objective of our study was to determine if the use of an app that matches phosphate binder dose with food phosphate content would be associated with an improvement in serum phosphate and a reduction in calcium carbonate intake compared with the multidisciplinary renal team. Eighty patients with ESKD treated with peritoneal dialysis at a tertiary care hospital in Canada were randomized to the standard of care for serum phosphate management (multidisciplinary renal team) versus the OkKidney app. Serum phosphate was measured at baseline and then monthly for 3 months with adjustments to phosphate management as deemed necessary by the multidisciplinary team (control) or the phosphate binder multiplier in the OkKidney app (intervention) on the basis of the laboratory values. The primary analysis was an unpaired t test of the serum phosphate at study completion. The participants were 56 (±14) years old, and 54% were men; the most common cause of ESKD was diabetes mellitus. The serum phosphate values were 1.96 (0.41) and 1.85 (0.44) mmol/L in the control and intervention groups, respectively, at the end of 3 months (P=0.30). The median elemental daily dose of calcium carbonate did not differ between the groups at study completion (587 mg [309-928] versus 799 mg [567-1183], P=0.29). The OkKidney app was associated with similar but not superior serum phosphate control to the standard of care, which included renal dietician support. US National Library Medicine ClinicalTrials.gov, NCT01643486.

Infectious Disease Acquisition in Pediatric International Travelers: A 10-Year Review at a Canadian Tertiary Care Hospital

Introduction: Children are frequent international travelers and may acquire serious infectious diseases during travel. We undertook a retrospective 10-year review examining children admitted to hospital with infectious diseases associated with international travel at a Canadian tertiary care pediatric hospital. Methods: Retrospective chart review was performed on select travel-related infectious diseases in children ranging in age from birth to <18 years who were admitted at the Hospital for Sick Children in Toronto between January 1st, 2009 and December 31st, 2018. Cases were identified using ICD-10 discharge codes. Patient demographics, travel history, epidemiological data, disease, and prophylaxis history were documented. Results: A total of 154 children were hospitalized with a travel-related infection over a 10-year period. The most common diagnoses were typhoid or paratyphoid fever (n = 58, 38%), malaria (n = 57, 37%), and hepatitis A (n = 14, 8%). The median age of those infected was 8 years (IQR 3-12). There were 120 (78%) children who were Canadian born, 31 (20%) immigrants and 3 (2%) who were visiting Canada. Of those who lived in Canada, 112 (90%) travelled for the purpose of visiting friends and relatives (VFR), 6 (5%) for tourism and 2 (2%) for humanitarian work. India was typically known for the acquisition of infection for typhoid or paratyphoid fever, and Nigeria for malaria. Hepatitis A was most commonly acquired in Pakistan. Conclusion: Imported infectious diseases continue to be a significant issue in travelers returning from trips suggesting improved preventative pre-travel care. VFR children are a group that should, in particular, be targeted for appropriate pre-travel advice and care.

Attitudes toward physical activity as a treatment component for adolescents with anorexia nervosa: An exploratory qualitative study of patient perceptions.

Anorexia nervosa (AN) with compulsive exercise is associated with poor treatment outcomes. This study sought to understand the attitudes of adolescents with AN from various stages of treatment, toward physical activity research practices and physical activity as a component of treatment. Seventeen adolescents 12-18 years old (15 female) with AN (10 with acknowledged history of compulsive exercise) were recruited from a Canadian Tertiary Care Hospital's Eating Disorder Program. Six inpatients, 5-day program patients, and six outpatients treated by either the inpatient and/or day treatment program in the past 2 years completed individual, semi-structured interviews that were audio-recorded and transcribed. Results were analyzed deductively using qualitative techniques. Participants recognized both benefits (psychological, sociological, and physiological) and risks (trigger negative thoughts, increase competitive behavior) of implementing physical activity into acute AN treatment. Patient characteristics, such as stage of treatment and exercise history, had an impact on participants' perceptions toward physical activity in AN. Participants suggested that the ideal physical activity program would be focused on fun, individualized and progressively integrated, group-based, and directly supported by staff. Although the majority of participants stated that they would wear an activity monitor for research purposes, concerns were voiced regarding compliance and the potential impact on eating disorder symptomatology. Participants overwhelmingly supported the careful implementation of structured physical activity and physical activity psychoeducation into the acute treatment of adolescents with AN. This study allows for the inclusion of patient voices in the conversation surrounding the role of physical activity in AN treatment.

Patients' and parents' perspectives of and experiences with assessing nursing students' paediatric clinical practice.

To explore patients' and parents' involvement in the formative assessment of undergraduate nursing students' paediatric clinical practice. We conducted semi-structured interviews with paediatric patients between 14 to 18years old and parents who received care from a nursing student while admitted to a paediatric tertiary care hospital in Canada. We analysed the data using qualitative content analysis as well as Lincoln and Guba's criteria for establishing trustworthiness. The Consolidated criteria for reporting qualitative studies (COREQ) checklist was completed for the quality appraisal of this article. Three categories emerged from the data: 1) how patients and parents are currently involved in the formative assessment of nursing students' paediatric clinical practice; 2) how patients and parents would prefer to be involved in the formative assessment of nursing students' paediatric clinical practice; and 3) the potential benefits and challenges of involving patients and parents in the formative assessment of nursing students' paediatric clinical practice. This study provided an understanding of patients' and parents' past encounters with nursing students and the elements of care that they have assessed as well as those that they would prefer to assess and provide feedback on, while considering the potential benefits and challenges of their involvement. The findings of this study will assist clinical instructors in determining how and when to involve patients and parents in the assessment of nursing students. Academic institutions offering nursing programmes should consider the study findings when improving or changing formative assessment strategies.

Factors Associated With Non-enrollment of Center-Based Cardiovascular Rehabilitation Program Among Transient Ischemic Attack or Mild Stroke Patients: A MIXED-METHOD RETROSPECTIVE STUDY.

Cardiovascular rehabilitation programs (CRPs) are effective in secondary stroke prevention, yet the enrollment rate is suboptimal. This study aims to identify demographic and clinical factors and patient-reported reasons for non-enrollment in a center-based outpatient CRP among patients with transient ischemic attack (TIA) or mild stroke. This mixed-method retrospective chart review was conducted in an outpatient CRP affiliated with a tertiary care hospital in Canada from January 2009 to October 2017. A total of 621 patients with TIA or mild stroke were included. Multiple logistic regression was used to determine the relationship between demographic and clinical predictors with non-enrollment. A thematic analysis of multidisciplinary progress notes was done for the non-enrollment subgroup of patients to understand the patient-reported reasons. The non-enrollment rate was 42%. Travel distance to CRP (OR = 1.024; 95% CI, 1.010-1.038), age (OR = 1.023; 95% CI, 1.004-1.042), and current smoking status (OR = 1.935; 95% CI, 1.230-3.042) were associated with non-enrollment. The patient-reported reasons for non-enrollment were occurrence of new medical events and comorbidities, their perceptions of health and CRP, transportation, work/time conflict, and distance. This study found that patients with TIA or mild stroke who were older, lived farther from the CRP center, or were current smokers were less likely to enroll in a CRP. The present findings may help clinicians identify patients unlikely to enroll in a CRP and allow the implementation of interventions focused on health education and physical activity to improve enrollment. Future research should validate these factors in multiple settings using prospective mixed methods so that interventions can be developed to address non-enrollment in the CRP.

The impact of delayed mobilization on post-discharge outcomes after emergency abdominal surgery: A prospective cohort study in older patients.

Surgeons are increasingly treating seniors with complex care needs who are at high-risk of readmission and functional decline. Yet, the prognostic importance of post-operative mobilization in older surgical patients is under-investigated and remains unclear. Thus, we evaluated the relationship between post-operative mobilization and events after hospital discharge in older people. Overall, 306 survivors of emergency abdominal surgery aged ≥65y who required help with <3 activities of daily living were prospectively followed at two Canadian tertiary-care hospitals. Time until mobilization after surgery was attained from hospital charts and a priori defined as ‘delayed’ (≥36h) or ‘early’ (<36h). Primary outcomes for 30-day and 6-month all-cause readmission/death after discharge were assessed in multivariable logistic regression. Patients had a mean age of 76 ± 7.7 years, 45% were women, 41% were ‘vulnerable-to-moderately-frail’, according to the Clinical Frailty Scale. Most common reasons for admission were gallstones (23%), intestinal obstructions (21%), and hernia (17%). Median time to post-operative mobilization was 19h (interquartile range 9−35); 74 (24%) patients had delayed mobilization. Delayed mobilization was independently associated with higher risk of 30-day readmission/death (19 [26%] vs. 22 [10%], P<0.001; adjusted odds ratio [aOR] 2.24, 95%CI 0.99–5.06, P = 0.05), but this was not statistically significant at 6-months (38 [51%] vs. 64 [28%], P<0.001; aOR 1.72, 95%CI 0.91−3.25, P = 0.1). One-quarter of older surgical patients stayed in bed for 1.5 days post-operatively. Delayed mobilization was associated with increased risk of short-term readmission/death. As older, more frail patients undergo surgery, mobilization of older surgical patients remains an understudied post-operative factor.Trial registration: clinicaltrials.gov identifier: NCT02233153

51 Overuse of ceftriaxone in children with otitis media: experience at a Canadian tertiary care hospital

Abstract Background Acute otitis media (AOM) is extremely common. In fact, most children experience at least one ear infection before starting school. It is also recognized as the most frequent reason to administer antibiotics in children. However, many advocate for limited use of antibiotics in healthy children over 6 months of age using a watchful waiting approach. This applies even more for broad-spectrum antibiotics in the context of antibiotic stewardship. The Canadian Paediatric Society (CPS) recommends using parenteral ceftriaxone only when oral drugs are not tolerated or amoxicillin-clavulanate fails. Objectives This primary aim of this study was to describe the use of ceftriaxone in the treatment of children with AOM. Secondary aims were to assess length of therapy and complications as well as determine if the use of ceftriaxone met the criteria of refractory AOM suggested by the CPS. Design/Methods We performed a retrospective observational cohort study of children aged between the ages of 6 months and 5 years with a diagnosis of AOM at a single tertiary care center. All children were seen between March 2017 and February 2019 in a pediatric outpatient medical day unit and received at least one dose of ceftriaxone. Chart review was performed and multiples variables were included in the analysis. Patients with insufficient chart data or with a congenital ear anomaly were excluded. Results A total of 276 patients were included. Patients were aged 17.5 ± 9 months and a majority were boys (N=160). Most patients were fully immunized (N=252). A history of penicillin allergy was reported for 59 patients. Previous AOM was common (N=205) while tympanostomy tubes were rare (N=12). With regards to the diagnosis of AOM, a majority (N=153) had bilateral AOM. Diagnosis of AOM was based on inflammation (N=204), bulging tympanic membrane (N=158) or middle ear effusion (N=118). Fourteen patients had a tympanic perforation. Almost all patients were febrile (N=266). One patient had a positive blood culture (streptococcus pneumoniae) and one had a mastoiditis. Among those who underwent bloodwork (N=212), white blood count was 15.2 ± 6.7 x 109. With regards to antibiotics, most patients (N=218) were initially given oral antibiotics, with amoxicillin given as a first line therapy for 99 patients. A minority of patients received amoxicillin-clavulanate prior to receiving ceftriaxone (N=105). Reasons for the use of ceftriaxone included intolerance to oral drugs (N=18), failure of (or recent exposure to) amoxicillin-clavulanate (N=89) and a history of penicillin allergy (N=50). Most patients were treated with a course of three days with only 51 patients receiving one or two doses. Conclusion In our cohort, the use of ceftriaxone was not limited to nonresponsive AOM. In fact, a minority of patients received ceftriaxone in the setting of intolerance to oral drugs or failure of amoxicillin-clavulanate. This goes against current CPS recommendations and suggests an overuse of broad-spectrum antibiotics. Obviously, this needs to be addressed in the context of antibiotic stewardship.